Cigna Agent of Record Letter for Lisa Chamberlain

Important Terms & Conditions, Please Read Carefully:

You’ve worked hard for each application you have submitted. This form is provided to ensure
that you receive credit for your efforts. Please complete this form for any Cigna Individual and Family policies you have sold, however are not identified as the Broker of Record. If you have more than one case, please use a separate form for each one. The completed form can be faxed to 877.484.5968.

Case Number or Customer ID (if available): *
Customer/Primary Applicant Name (as submitted on the application):*
Customer's/Primary Applicant's Social Security Number:*
Customer's/Primary Applicant's Physical Address:*
Coverage Effective Date:*
On Marketplace:*
(*to be completed by Agent prior to submission)

Primary Agent Name: Lisa Chamberlain
Cigna Producer Code:
NPN : 16670644

Writing Agent Name (if different from above):
Cigna Producer Code
NPN :

By signing below, I confirm that I assisted the aforementioned customer with their Cigna enrollment.
Broker Signature:
Date:

NBM ONLY Enter Name:
If applicable, explain below the reason for Broker of Record update request.